Conventional Chest Tube vs Pigtail Catheter

Traditionally, hemothorax and pneumothorax in trauma has been treated with chest tubes. I’ve previously written about some of the debate regarding using smaller tubes or catheters. A paper that will be presented at the EAST meeting in January looked at pain and failure rates using 14Fr pigtail catheters vs 28Fr chest tubes.

This was a relatively small, prospective study, and only 40 of 74 eligible patients were actually enrolled over 20 months at a Level I trauma center in the US. Pain was measured using a standard Visual Analog Scale, as was complication and failure rate, tube duration and hospital stay.

The following interesting findings were noted:

  • Chest wall pain was similar. This is expected because the underlying cause of the pneumothorax, most likely rib fractures, is unchanged.
  • Tube site pain was significantly less with the pigtail
  • The failure rate was the same (5-10%)
  • Complication rate was also the same (10%)
  • Time that the tube was in, and hospital stay was the same

Bottom line: There may be some benefit in terms of tube site pain when using a smaller catheter instead of a chest tube. But remember, this is a very small study, so be prepared for different results if you try it for your own trauma program. If you do choose to use a smaller tube or catheter, remember to do so only in patients with a pure pneumothorax. Clotted blood from a hemothorax will not be completely evacuated.

Reference: A prospective randomized study of 14-French pigtail catheters vs 28F chest tubes in patients with traumatic pneumothorax: impact on tube-site pain and failure rate. EAST Annual Surgical Assembly, Oral paper 12, 2013.


ALiEMU Capsules Module 8: Venous Thromboembolism

We are proud to present Capsules Module 8: Venous Thromboembolism, now published on ALiEMU. Here is a summary of the key points from this outstanding module by Drs. Jill Logan and Doug Gowen.

Go to ALiEMU module

Summary: Venous Thromboembolism

Venous thromboembolisms (VTE) constitute disease states with a wide array of presentations ranging from incidental findings to imminent mortal peril. Treatment of these disease states necessitates a comprehensive understanding of the delicate balance of the pro-coagulant and anti-coagulant forces within the body and their means of manipulation through pharmacologic intervention. This Capsule will assist the reader in their understanding and application of current therapeutic interventions for VTE as well as invite the reader to explore the evidence behind these recommendations. This preview highlights a few Capsules in this module.

Oral Anticoagulation for VTE

Warfarin has traditionally been the best (and only) available oral anticoagulant in our arsenal, however, a substantial practice shift has occurred with numerous direct oral anticoagulants (DOAC) now available. These DOACs have been approved to treat both deep vein thromboses (DVTs) as well as pulmonary embolisms (PE) and may now be considered first-line in patients without cancer.


Warfarin is notorious for drug-drug interactions but care should still be used with the DOACs when combined with p-glycoprotein inhibitors and inducers.

Parenteral Anticoagulation for VTE

At times, parenteral anticoagulation may be indicated over oral therapy. For example, low molecular weight heparins (LMWHs) remain the drug of choice for patients with VTE and active cancer. Additionally, when using warfarin, bridge therapy is recommended for a minimum of five days to assure adequate anticoagulation while achieving a therapeutic INR. Heparin therapy offers an advantage in patients who are unstable or in whom surgical intervention may become necessary due it’s relatively short duration of action and ability to be reversed with protamine.

Some DOAC agents necessitate treatment with parenteral anticoagulation for 5 days prior to initiation for VTE.

VTE in Pregnancy

Pregnancy is a hypercoagulable state and the risk of VTE increases as gestation progresses. LMWHs are the treatment of choice in pregnancy, however, therapeutic doses of subcutaneous heparin may also be an option. The DOAC agents have not been tested in pregnancy and due to unknown effects on the fetus, their use is not recommended.

Warfarin may be teratogenic and should not be used in pregnancy.

VTE in Pediatrics

LMWHs have become the agent of choice for the treatment of VTE in children, however, there is very little published clinical data to support one therapy over another. Unlike adult patients receiving LMWHs, therapeutic drug monitoring is recommended for all pediatric VTE patients receiving this therapy.

Use extreme caution when prescribing anticoagulation in pediatrics to avoid dosing errors due to concentration differences among anticoagulants.

Breakthrough Clotting

From time to time, the ED provider may be presented with a patient on therapeutic anticoagulation presenting with a new clot or clot worsening. After assessment of compliance and investigation of potential drug-drug interactions to ensure therapeutic anticoagulation has been maintained, therapy may be switched to LMWH therapy. If the patient was already receiving LMWH, a temporary dose increase by approximately 25% may be considered.

Many of the DOAC agents have different dose recommendations based on indication. Ensure patients with breakthrough clots were prescribed the correct DOAC dose before considering the therapy a failure.

Hemodynamically Unstable PE Management

Thrombolytic therapy may be considered for massive PE and some select submassive PE patients. Alteplase is approved for use in massive PE as a 2 hour infusion of 100 mg. Patient acuity may necessitate more rapid intervention and administration of thrombolytic via intravenous push has been suggested. Alternatively, some evidence suggests that lower thrombolytic doses may be appropriate in submassive PE patients.

Resuscitation efforts are recommended to continue for 15-20 minutes following thrombolytic administration in cardiac arrest situations.

Course Contributors

Role Team Member Background
Authors Jill Logan, PharmD, BCPS @EMPharm EM Pharmacist, University of Maryland Medical Center
Doug Gowen, PharmD, BCPS @DougEDPharm EM Pharmacist, Glens Falls Hospital
PharmD Reviewers Michelle Hines, PharmD, BCPS @mEDPharmD EM Pharmacist, University of Maryland Medical Center
Paul Takamoto, PharmD @ptakpharm EM Pharmacist, University of California San Francisco
Associate Editor Craig Cocchio, PharmD, BCPS @iEMPharmD EM Pharmacist, Trinity Mother Frances Hospital
Physician Reviewer David Juurlink, BPharm, MD, PhD, FRCPC @DavidJuurlink Professor of Medicine, University of Toronto
Copy Editor Meghan Groth, PharmD, BCPS
EM Pharmacist, UMass Memorial Medical Center
Creator and Lead Editor Bryan Hayes, PharmD, FAACT, FASHP @pharmertoxguy EM Pharmacist, Massachusetts General Hospital; Assistant Professor of EM, Harvard Medical School


Author information

Bryan D. Hayes, PharmD, FAACT, FASHP

Bryan D. Hayes, PharmD, FAACT, FASHP

Chief Science Officer, ALiEM
Creator and Lead Editor, CAPSULES series, ALiEMU
Clinical Pharmacist, EM and Toxicology, MGH
Assistant Professor of EM, Harvard Medical School

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